Research article

How much do disuse syndrome patients improve withconvalescent rehabilitation? Assessment of improvement
Katsuo Usuda 1, Takahiko Uesaka 1, Takeshi Okubo 1, Takashi Shimada 1, Chieko Shimada 1, Haruhide Ito 1,
Norihito Douko 1, Takuya Aoki 1, Mayumi Takada 1, Keiji Yokoyama 1, Masahiro Shimizu 1, Kengo Kitagawa 1,
Naoaki Itamoto 1, Osami Shimada 1
Citation:
Usuda K., Uesaka T.,
Okubo T., Shimada T., Shimada C.,
Ito H., Douko N., Aoki T., Takada
M., Yokoyama K., Shimizu M., Kitagawa K., Itamoto N., Shimada O.How much do disuse syndrome
patients improve with convalescentrehabilitation?
Assessmentof
improvement
Balneo and PRM Research Journal
2024, 15(2): 688
Academic Editor(s):Constantin Munteanu
Reviewer Officer:
Viorela Bembea
Production Officer:
Camil Filimon
Received: 14.03.2024
Published: 21.06.2024
Reviewers:
Constantin Munteanu
Elena Valentina Ionescu
Publisher’s Note: Balneo and PRM
Research Journal stays neutral withregard to jurisdictional claims inpublished maps and institutional affiliations.
Copyright: © 2023 by the authors.
Submitted for possible open-accesspublication under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

1

Department of Rehabilitation Medicine, Shimada Hospital, Fukui, Japan* Correspondence: Katsuo Usuda, usan930@gmail.com

Abstract: The purpose of this study is to determined characteristics of FIM gain after rehabilitation
for patients with disuse syndrome and what factors are beneficial for increasing FIM gain. The
subjects were 168 patients (87 males and 81 females). We investigated the relationship between the
degree of FIM gain and etiology, age, sex, gender, history of cerebrovascular disease, dementia,
body weight, body mass index(BMI), hemoglobin, protein, albumin, prognostic nutritional index,
malnutrition, and dysphagia. The primary etiologies that resulted in disuse syndrome were COVID19, respiratory disease, gastrointestinal disease, urinary disease, cardiovascular disease, and others.
The average FIM-total gain by age decreased as age in-creased. FIM-total gain was 8.0 for patientsin their 90s. FIM-total gain was 13.8 for patients with no past incident of cerebrovascular diseases,
7.6 for one past incident, and 4.0 for two or more past incidents. FIM-total gain of the patients ofsevere dysphagia was significantly lower than that of the patients of normophagia / mild or
moderate dysphagia. There was a mild correlation between FIM-total gain and gain of body weight(r=0.21) and between FIM-total gain and gain of BMI (r=0.21). Patients with disuse syndrome over
90 or with two or more incidents of cerebrovascular diseases should be treated, not in rehabilitation
but in nursing care.
Keywords: Disuse syndrome; Rehabilitation; Malnutrition; Dysphagia; Functional independence
measure (FIM)

1. Introduction
Disuse syndrome is defined as a "secondary disorder caused by a state of inactivity" (1).
Many human functions are weakened due to bed rest, even if they are not due to disease,and further rest leads to pathological functional decline, resulting in a secondary
complication.
Aging populations worldwide are increasing, and older adults account for more than
25% of the population in Japan. Everyone wishes for a healthy retirement, but people
spend more than a few years at the end of their lives being bedridden. It is essential foreveryone needs to spend those years with peace of mind. Many older adults suffer fromdisuse syndrome at the end of life. It is caused by immobility and nutritional deficiencies,
and those patients need rehabilitation. Malnutrition is not paticular in patients with thedisuse syndrome (2). For patients with disuse syndrome it is essential to improve not only
early mobilization and functional training but also their nutritional condition. It isessential to know the characteristics of disuse syndrome and to prevent disuse syndrome.
With the development of medical research in space in correlation with NASA since the1960s, symptoms such as orthostatic low pressure, decreased cardiopulmonary function,and osteoporosis, similar to the disuse syndrome after long-term bed rest, have appeared

Balneo and PRM Research Journal 2024, 15, 2 https://doi.org/ 10.12680/balneo.2024.688

http://bioclima.ro/Journal.htm

Balneo and PRM Research Journal 2024, 15, 2

2 of 10after short-term spaceflights (1). The adverse effects of not exercising have been
demonstrated (1).
Rehabilitation is not always beneficial for some patients with disuse syndrome. Suchpatients require not rehabilitation but nursing care. The effects of rehabilitation for disuse
syndrome in older adults requiring severe care, we can consider an indication of therehabilitation and also an indication of nursing care. The functional independence
measure (FIM) is the most widely used and essential for rehabilitation in the world.
In this article, we determined characteristics of FIM gain after rehabilitation for patientswith disuse syndrome and what factors are beneficial for increasing FIM gain.
2. Materials and Methods
This study was approved by the Shimada Hospital Ethics Committee (No.2209). It wasa retrospective cohort study and conducted at a single institution for patients with disuse
syndrome who were hospitalized from May 2020 to November 2023. In this paper, to know
the overall picture of patients with disuse syndrome, we had correlated andanalyzed allcases treated for rehabilitation in one private convalescent hospital during a three and a halfyear period. This retrospective study was using the data of 168 registered subjects. Inclusion
criteria for this study were a diagnosis of the disuse syndrome and age older than 20 yrs.
There were no exclusion criteria. Finally, 168 patients were registered in the study.
All patients received intensive rehabilitation by qualified physical therapists, qualified
occupational therapists and qualified speech-language-hearing therapists. Patients weretreated in the full-time integrated treatment (FIT) program (3) managed by rehabilitation 7
days/wk, encouragement of daytime activity, and enhanced communication and collaboration amongst staff sharing in detail patients treatment and progression. Patients who were
78 years or younger had 3 hours of rehabilitation (physical therapy 1 hour, occupational
therapy 1 hour, speaking therapy 1 hour), and patients who were 79 years or older had 2
hours of rehabilitation (physical therapy 40 minutes, occupational therapy 40 minutes,
speaking therapy 40 minutes). When occupational therapy or speaking therapy was notnecessary for patients, physical therapy was given instead. Several members of a nutrition
support team (NST) improved the nutritional condition of the patients with disuse syndrome. Nutritional status was assessed at referral by collecting data on hemoglobin, total
protein, albumin, and BMI. This data was used to determine the amount calories and thenutrients that should be consumed by each patient.
Clinical and demographic features including primary etiology, sex, age, history of
cerebrovascular diseases, dementia, body weight (Kg), body mass index (BMI), serum
hemoglobin [Hb (g/dl)], serum total protein [TP (g/dl)], serum albumin [Alb (g/dl)],
prognostic nutritional index (PNI), malnutrition and dysphagia were analyzed. PNI was
calculated by 10 × Alb (g/dl) + 0.005 × total lymphocyte count (/mm³) (4). Dysphagia isclassified as follows: normophagia / mild dysphagia suggests that a patient can have a total
oral diet at admission. Moderate dysphagia suggests that a patient cannot have a total oral
diet at admission but can have it at discharge. Severe dysphagia suggests that a patientcannot have a total oral diet at admission and cannot have a total oral diet at discharge as
well. Presence of malnutrition were defined as meeting one or more of a BMI<18.5 kg/m2,
Hb level<10.0 g/dl, Alb level<3.0 g/dl, or total lymphocyte count<1200 cells/mm 3 (2).
Functional status was assessed by using the functional independence measure (FIM).
FIM was calculated every week and evaluated at admission, 4 weeks, 8 weeks after
admission, and discharge. The FIM items are classified into total, motor and cognitive
categories (FIM-total, FIM-motor, and FIM-cognition). FIM scores were assigned according
to a 7-point scale, and the score indicated the amount of assistance required to perform each
item (7 = totally independent and 1 = dependent or not testable) (5).

Balneo and PRM Research Journal 2024, 15, 2

3 of 10

Statistical Analysis
The data is presented as the mean ± standard deviation. A non-parametric test (Mann–
Whitney U test) was applied to compare the mean values of the two groups. The statisticalanalyses were performed based on StatView for Windows (Version 5.0; SAS Institute Inc.
Cary, NC, USA). A p-value of < 0.05 was defined as statistically significant.
3. Results
Eighty-seven patients were male and 81 were female (Table 1). Their mean age was
83.2±8.7 (range 44 to 99). Primary etiologies of disuse syndrome were COVID-19 in 13
cases, respiratory disease in 91 cases, gastrointestinal disease in 24 cases, urinary disease in
13 cases, cardiovascular disease in 11 cases, sepsis in 5 cases, orthopedic disease in 5 cases,
heatstroke/dehydration/hypothermia in 4 cases, and dementia in 2 cases.
Table 1.

Patients characteristics

44 ～ 99

Age

Sex

Primary
Etiology

Male87

Female（Mean±S.D. : 83.2±8.7）

History of cerebrovasculardiseaseNo incidence

124

81

One time incidence

42

COVID-19

13

Two or more times
incidence2

Respiratory disease91

Positive

75

Gastrointestinal disease24

Negative

93

Urinary disease

13

Home

94

Cardiovascular disease11

Hospital,Nursing home73

Sepsis

5

Death

1

Orthopedic disease5

Heatstroke/dehydration/ hypothermia

4

Dementia

2

Dementia

Discharge

The days until the start of rehabilitation were 6.8 ± 9.5 (range 0 to 62), and the days of
hospitalization in convalescent hospital were 51.9 ± 19.6 (range 7 to 100). At admission, FIMtotal of all patients was 50.6±25.3 (range 18 to 112), FIM-motor was 32.3±18.3 (range 13 to 79),
and FIM-cognition was 18.2±8.7 (range 5 to 35).
At discharge, FIM-total gain was 12.1±15.5(range -18 to 80), FIM-motor gain was 10.9±13.7 (range -16 to 65), and FIM-cognition gain was
1.5±2.9 (range -4 to 17).
The averages of FIM-total by primary etiology were 73.0±28.6 for cardiovascular disease,72.8±29.9 for heatstroke/dehydration/hypothermia, 65.4±19.4 for urinary diseases, 60.8±10.5
for orthopedic diseases, 56.0±28.1 for gastrointestinal diseases, 52.8±19.0 for sepsis, 51.7±24.5
for COVID-19, 50.0±33.9 for dementia, and 42.5±22.6 for respiratory diseases (Figure 1A).
Patients with cardiovascular disease or heatstroke/dehydration/hypothermia had higher
FIM-total at admission. The averages of FIM-motor and FIM-cognition by primary etiology
were presented in Figure 1B and 1C.

Balneo and PRM Research Journal 2024, 15, 2

4 of 10Figure 1. A: FIM-total at admission based on primary etiology
B: FIM-motor atadmission based on primary etiology C: FIM-cognition at admission based on
primary etiology
At admission, the average was 47.4±12.5 for body weight, 19.8±4.2 for BMI, 11.5±1.7 forHb, 6.5±0.7 for TP, 3.0±0.6 for Alb, and 36.6±6.2 for PNI. The averages of FIM-total gain atdischarge by primary etiology were 24.6±21.8 for COVID-19, 22.6±23.0 for cardiovasculardisease, 18.8±5.7 for heatstroke/dehydration/hypothermia, 13.4 for sepsis, 13.0±14.2 fordementia, 12.2±15.6 for orthopedic diseases, 12.1±11.5 for urinary diseases, 9.8±12.5 forgastrointestinal diseases and 9.3±14.1 for respiratory diseases (Figure 2A). Patients with
COVID-19 or cardiovascular disease had higher FIM-total gain at discharge. The averages of
FIM-motor gain and FIM-cognition gain at discharge by primary etiology were presented in
Figure 2B and 2C. Patients with cardiovascular disease or dementia had higher FIMcognition gain of 3 or more at discharge.

Figure 2. A: FIM-total gain at discharge based on primary etiology
B: FIM-motor
gain at discharge based on primary etiology C: FIM-cognition gain at discharge basedon primary etiology
The average FIM-total at admission by age was 101.5 for patients in their 40s - 50s, 69.9
for those in their 60s, 49.9 for those in their 70s, 53.3 or those in their 80s, and 39.6 for those in
their 90s, decreasing as age increased (Figure 3A). The average FIM-total gain by age was 15.0
for patients in their 40s - 50s, 14.3 for those in their 60s, 14.4 for those in their 70s, 13.0 for
those in their 80s, and 8.0 for those in their 90s, decreasing as age increased (Figure 3B). The
average FIM-cognition gain by age was 0.5 for patients in their 40s - 50s, 1.3 for those in their

Balneo and PRM Research Journal 2024, 15, 2

5 of 1060s, 1.3 for those in their 70s, 1.9 for those in their 80s, and 1.0 for those in their 90s. FIMtotal gain of the females was 12.9 ±14.9, which is not significantly better than that (11.4±16.1)of the males. (p=0.546). Regarding the history of cerebrovascular diseases, FIM-total gain was
13.7 for patients with no incident, 7.6 for one incident, and 4.0 for two or more incidents(Figure 3C); the more the history of cerebrovascular diseases, the lower the FIM-total gain.
The average of FIM-total gain for the 75 patients with dementia was 11.0, which tended to belower than the 13.0 for the 93 patients without dementia (Figure 3D). 139 patients (83%)
were diagnosed with malnutrition. FIM-total gain at discharge of 139 patients withmalnutrition was 11.8±15.9, which was likely to be worse than that (13.9±13.9) of the 29
patients without malnutrition, but there was not a significant difference (r=0.496).

Figure 3
A: FIM-total at admission based on age. B: FIM-total gain at discharge basedon age. C: Past history of cerebrovascular diseases. D: FIM-total gain at discharge basedon dementia
Concerning the degree of dysphagia, FIM-total at admission of the patients ofnormophagia / mild dysphagia was 58.7±24.5, which was significantly higher than that(30.5±9.2) of the patients with moderate dysphagia or that (27.8±12.1) of the patients withsevere dysphagia (Figure 4A). FIM-total gain at discharge of the patients with severe
dysphagia was 5.6±8.8, which was significantly lower than that (13.1±15.3) of the patientswith normophagia / mild dysphagia or that (14.1±20.8) of the patients with moderate
dysphagia (Figure 4B).

Figure 4.
A: FIM-total at admission based on the degree of dysphagia.
B: FIM-total gain at discharge based on the degree of dysphagia
There was a tendency for cases in which rehabilitation was introduced earlier to have ahigher FIM-total gain (Figure 5A). A tendency was observed that the longer thehospitalization period, the higher FIM-total gain (Figure 5B). There was an excellent
relationship between FIM-total gain at discharge and FIM-total gain at 4 weeks after
admission (r=0.89)（Figure 5C).

Balneo and PRM Research Journal 2024, 15, 2

6 of 10Figure 5. A: FIM-total gain at discharge and days of rehabilitation introduction after
onset
B: FIM-total gain at discharge and hospitalization period
C: FIM-total gain
at discharge and FIM-total gain at 4 weeks after admission
There were mild correlations between FIM-total gain and gain of body weight (r=0.21)(Figure 6A), and between FIM-total gain and gain of BMI (r=0.21) (Figure 6B). There were
not significant correlations between FIM-total gain and gain of TP (r=0.045)（Figure 6C）or between FIM-total gain and gain of Alb (r=0.016 )(Figure 6D). There were no significant
correlations between FIM-total gain and gain of Hb (r=0.084) (Figure 6E). There were no
significant correlations between FIM-total gain and body weight at admission (r=0.13), or
between FIM-total gain and Alb at admission (r=0.16)（Figure 6F）. There was a tendency
of a mild correlation between FIM-total gain and PNI (r=0.19)（Figure 6G）.

Figure 6.
A:FIM-total gain at discharge and gain of body weight
B: FIM-total gain at discharge
and gain of body BMI (Body Mass Index) C: FIM-total gain at discharge and gain of protein D: FIMtotal gain at discharge and gain of protein E: FIM-total gain at discharge and gain of hemoglobin
F:
FIM-total gain at discharge and albumin at admission
G: FIM-total gain at discharge and PNI(prognostic nutritional index)

Balneo and PRM Research Journal 2024, 15, 2

7 of 10

4. Discussion
To know the overall picture of patients with disuse syndrome, we had correlated andanalyzed all cases treated for rehabilitation in one private convalecent hospital during a threeyear and a half period. Our cases would represent the broader population with disuse
syndrome. For improving the rehabilitation for patients with disuse syndrome, it is essential
to understand the details of FIM gain based on the etiology and clinical factors.
Barthelindex (6) is also useful for rehabilitation, but the evaluation of Barthel index is rough and does
not lend itself to detailed analysis.
Early rehabilitation
There was a tendency for cases where rehabilitation was introduced earlier to have ahigher FIM-total gain. Nutritional and exercise therapy should be started very early after
admission and adjusted to the level of inflammation and disease status (7).
Earlyrehabilitation was beneficial treatment for osteoporotic vertebral fractures to reduce the riskfor disuse syndrome, maintain pre-injury ADL status, and minimize the medical costs (8).
Early rehabilitation was already recommended to be effective for stroke patients (9). The
Intercollegiate Stroke Working Party (ICSWP) recommended that stroke rehabilitation
should begin 24-48 hours after a stroke and should be reviewed at six months (10). Althoughpatients with an early rehabilitation start had lower FIM admission scores than patients witha late start, patients with an early rehabilitation start experienced more remarkable functional
improvement (11). There was a relationship between the early rehabilitation start and better
functional improvement (12).
Characteristics of factors:
A tendency was observed that the longer the hospitalization period, the higher the FIMtotal gain. There was an excellent relationship between FIM-total gain at discharge and FIMtotal gain at 4 weeks after admission (r=0.89). FIM-total gain at 4 weeks after admission was
revealed to be a prognostic predictor of patients with disuse syndrome. At admission,
patients with cardiovascular disease or heatstroke/dehydration/hypothermia are revealed tohave higher FIM-total compared to other etiology. And the average FIM-total at admission
by age reveals decreased according to age increase. Patients with COVID-19 or cardiovasculardisease, having higher FIM-total gain at discharge, were good candidates for rehabilitation ofdisuse syndrome. The average of FIM-total gain by age was decreased as age increased. FIMtotal gain of the patients with dementia tended to be lower than that of the patients without
dementia. FIM gain decreased according to repeating incidents of cerebrovascular diseases.
Patients with no previous cerebrovascular disease were good candidates for rehabilitation ofdisuse syndrome.
Malnutrition
Wakabayashi H, et al. (2) reported that 91% of patients with disuse syndrome were malnourished. In our series, 83% of patients were malnourished. Malnutrition is common inpatients with disuse syndrome. Rehabilitation outcome was worse in malnourished patients
than patients with normal nutrition (relative risk: 0.72, p=0.04) (2), although our data did notshow a significant difference. There was not a significant correlation between FIM-total gain
and gain of Hb (r=0.084) in this study. Still hemoglobin levels were reported to be associatedindependently with rehabilitation outcomes (odds ratio 2.34, p=0.005) (2). Patients with low
hemoglobin levels and PNI at referral are more likely to have a poor rehabilitation outcome(2). In our study, there were mild correlations between FIM-total gain and gain of bodyweight (r=0.21), between FIM-total gain and gain of BMI (r=0.21), and between FIM-total gain
and PNI (r=0.19). However, there were no significant correlations between FIM-total gain
and gain of protein (r=0.045), between FIM-total gain and gain of albumin (r=0.016), between
FIM-total gain and body weight at admission (r=0.13) or between FIM-total gain and albuminat admission (r=0.16).

Balneo and PRM Research Journal 2024, 15, 2

8 of 10Dysphagia:
Dysphagia is one of the most prevalent and distressing symptoms among palliative carepatients (13). Dysphagia was found to be closely associated with malnutrition and sarcopenia(14). A combination of a decrease in activity of daily living (ADL) and cognitive dysfunction
influence the outcome of dysphagia (15). In this study the patients of normophagia / mild
dysphagia had 58.7±24.5 of FIM-total at admission and get 13.1±15.3 of FIM-total gain atdischarge. The patients of moderate dysphagia had 30.5±9.2 of FIM-total at admission, and
14.1±20.8 of FIM-total gain at discharge. However the patients of severe dysphagia had
27.8±12.1 of FIM-total at admission, but got only 5.6±8.8 of FIM-total gain at discharge. Ourdata revealed that improving dysphagia is essential for patients with disuse syndrome.
Sarcopenia:
Secondary sarcopenia is often observed in disuse syndrome. Evaluation and treatment ofsarcopenia are also necessary. In 2010, the European Working Group on Sarcopenia in Older
People published the following statement: “Sarcopenia is a syndrome characterized by aprogressive and generalized loss of skeletal muscle mass and strength, with a risk of adverse
outcomes, such as physical disability, poor quality of life and death”(16). The Asian Working
Group for Sarcopenia (AWGS) 2014 consensus defined sarcopenia as "age-related loss ofmuscle mass, plus low muscle strength, and/or low physical performance"(17). Subsequently,
in October 2016, sarcopenia was included in the ICD-10 (M62.84) and was internationallyrecognized as a disease (18). The term, sarcopenia, is a combination of the Greek word sarx,
meaning muscle, and penia, meaning to lose. Muscle mass is reduced by about 1%–2% every
year after age 50 (19,20). Nutritional management and exercise are crucial for the prevention
and treatment of sarcopenia (7). Excessive bed rest and mismanagement of nutrition in
medical facilities can lead to iatrogenic sarcopenia (16). It has been reported that 14.7% of
older patients who did not have sarcopenia before hospitalization had new-onset sarcopenia
at discharge (21). In recent years, “sarcopenia and dysphagia” have become a hot topic inseveral academic meetings and conferences of medical and healthcare professionals. The
expression “dysphagia due to sarcopenia” was first introduced in 2005 (22), whereas the term
“sarcopenic dysphagia” was first used in the paper published by Kuroda et al. in 2012 (23).
The prevalence of malnutrition and sarcopenia in physically disabled elderly patients who
undergo rehabilitation is high (24).
Osteoporosis:
Greenleaf et al. (25) found that long-term bed rest reduces stress on bones in the longitudinal direction, allowing the body to interpret this as a state in which bone mass is nolonger needed, promote the excretion of calcium and phosphorus, and initiate bed rest. It
states that a decrease in bone density occurs after two weeks.
Indication of nursing care
From the viewpoint of cost benefit, 90 or more year-old patients with disuse syndrome,
whose FIM-total gain was 8.0, could be treated in nursing care, not rehabilitation. Patients
who had two or more incidents of cerebrovascular diseases with disuse syndrome, whose
FIM-total gain was 4.0, could also be treated in nursing care, not rehabilitation.
Clinical practice for patients with disuse syndrome should start as soon as possible after
its onset. Nutritional status and swallowing function are key factors for improving disuse
syndrome. But patients with disuse syndrome over 90 or with two or more incidents of
cerebrovascular diseases should be treated, not in rehabilitation but in a nursing home.
The average age of our patients was 83.2±8.7 (range 44 to 99), which represented older
patients. Younger patients with disuse syndrome achieved better FIM gain than older
patients.
Average FIM-total gain by age was 15.0 for patients in their 40s - 50s, 14.3 forthose in their 60s, 14.4 for those in their 70s, 13.0 for those in their 80s, and 8.0 for those in
their 90s, decreasing as age increased. For future research, a study of younger patients withdisuse syndrome has high value and would be beneficial.

Balneo and PRM Research Journal 2024, 15, 2

9 of 10A healthcare team consists of not only doctors, nurses, and therapists, but also medicalsocial workers, care managers and facility staff. Relationships among them are essential for
improving quality of life of patients with disuse syndrome.
Study limitations We have to keep in mind that the research had five limitations. First, it
was a retrospective research project and was conducted at a single institution. Second, thenumber of patients of disuse syndrome was only 168. For a more accurate assessment,
additional patients with disuse syndrome and more extended follow-up studies are necessary.
Third, this study did not have a control group. In a private convalecent hospital, it is rather
difficult to add a control group with disuse syndrome for comparison to a study group. In
the control group patients cannot get rehabilitation. Most patients with disuse syndrome
want to get rehabilitation because there is evidence of the efficacy of this treatment. Forth,after discharge from our hospital, most patients underwent follow-up observation at theirfamily doctors, while others were admitted to other hospitals or nursing homes. Long term
outcomes of rehabilitation for disuse syndrome are not clear yet, so we have work with theirhome doctors, hospitals and nursing homes, and evaluate the long-term outcomes. Fifth,
selection bias might be present in the study. These patients with disuse syndrome would be
more interested in healthcare and want to get rehabilitation compared to the broader
population with disuse syndrome.
5. Conclusions
To increase the degree of FIM improvement in patients with disuse syndrome, it isessential to start rehabilitation early after the onset of symptoms. A sufficient hospitalization
period is required, and it is desirable to improve body weight and BMI through dietary intake.
Improving of dysphagia is essential for the patients with disuse syndrome. Patients withdisuse syndrome over 90 years old or with two or more incidents of cerebrovascular diseases
should be treated, not in rehabilitation but in nursing care.
Supplementary Materials: none
Author Contributions: Conceptualization, Usuda K. and Uesaka T.; methodology, Okubo T.;
software, Takeda M.; validation, Yokoyama K., Shimizu M., and Kitagawa K.; formal analysis,

Shimada T. and Shimada C.; investigation, Ito H.; data curation, Itamoto N.; writing—original draft
preparation, Usuda K.; writing—review and editing, Usuda K.; visualization, Douko N. and Aoki T.;
supervision, Shimada O. All authors have read and agreed to the published version of the manuscript.
Funding: none
Institutional Review Board Statement: This study was approved by the Shimada Hospital

Ethics Committee (No.2209).

Written consent was obtained from all participants.

Informed Consent Statement: An informed consent was obtained from each patientparticipating in the study.

Acknowledgments: We appreciate many therapists who perform intensive rehabilitation
for patients and who also evaluated the outcomes. We also appreciate Dustin Keeling who
aided in the proofreading of our research.
Conflicts of Interest: The authors declared no conflict of interest.

References
1. Halar EM. Et al. Physical medicine and rehabilitation. Principal and practice. 4th Ed, Lippincott
Williams & Wilkins, Philadelphia, 2005. P.1447-67.
2. Wakabayashi H, Sashika H. Association of nutrition status and rehabilitation outcome in the disuse
syndrome: a re-trospective cohort study Gen Med: 2011; 12:69-74.
3. Sonoda S, Saitoh E, Nagai S, Kawakita M, Kanada Y. Full-time integrated treatment program, a new
system for stroke rehabilitation in Japan. Am J Phys Med Rehabil 2004; 83: 88-93.
4. Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of
malnourished cancer pa-tients. Nihon Geka Gakkai Zasshi 1984;85(9):1001-5. PMID: 6438478

Balneo and PRM Research Journal 2024, 15, 2

10 of 10

5. Robinson-Smith G, Johnston MV, Allen J: Self-care self-efficacy, quality of life, and depression after
stroke. Archives of Physical Medicine and Rehabilitation 2000; 81 (4): 460-4. doi:
10.1053/mr.2000.3863
6. Mahoney FI, Barthel DW. Functional evaluation: The barthel index. Md State Med J. 1965:14: 615.
7. Kakehi S, Wakabayashi H, Inuma H, Inose T, Shioya M, Aoyama Y, et al. Rehabilitation nutrition andexercise thera-py for sarcopenia World J Mens Health 2022; 40(1): 1–10. doi: 10.5534/wjmh.200190
8. Norimoto M, Yamashita M, Yamaoka A, Yamashita K, Abe K, Eguchi Y, et al. Early mobilization
reduces the medical care cost and the risk of disuse syndrome in patients with acute osteoporotic
vertebral fractures. J Clin Neurosci 2021; 93: 155-9. doi: 10.1016/j.jocn.2021.09.011.
9. Hayes SH, Carroll SRI. Early intervention care in the acute stroke patient, Arch Phys Med Rehabil
1986; 67: 319-21.
10. Anthony George Rudd, A Audrey Bowen, B Gavin R Young C and Martin A James. The latest
National clinical guide-line for stroke. Clinical Medicine 2017; 17 (2): 154–5.
11. Öz B, Koca B, Ölmez N, Memiş A. Factors associated with functional and cognitive improvement inpatients with stroke after rehabilitation. Turkish Journal of Physical Medicine and Rehabilitation
2008; 54 (3): 84-9 (article in Turk-ish with an abstract in English).
12. Paolucci S, Antonucci G, Grasso MG, Morelli D, Troisi E, Coiro P, et al. Early versus delayed
inpatient stroke rehabili-tation: a matched comparison conducted in Italy. Archives of Physical
Medicine and Rehabilitation 2000; 81 (6): 695-700. doi: 10.1016/s0003- 9993(00)90095-9
13. Kunieda K, Ohno T, Fujishima I, Hojo K, Morita T. Reliability and validity of a tool to measure theseverity of dysphagia. The food intake LEVEL scale. J Pain Symptom Manage 2013; 46 (2): 201-6.
14. Matsuo H, Sakuma K. Pathophysiology of cachexia and characteristics of dysphagia in chronic
diseases. Asia Pac J Oncol Nurs 2022; 9(10):100120. doi: 10.1016/j.apjon.2022.100120.
15. Kojima A, Imoto Y, Osawa Y, Fujieda S. Predictor of rehabilitation outcome for dysphagia. Auris
Nasus Larynx. 2014 Jun;41(3):294-8. doi: 10.1016/j.anl.2013.12.009.
16. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, , Boirie Y, Cederholm T, Landi F, et al. Sarcopenia:
European consensus on definition and diagnosis: Report of the European Working Group on
Sarcopenia in Older People. Age Ageing 2010; 39: 412–23.
17. Chen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K. et al. Asian working groupfor sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc
2020; 21(3) : 300-7.e2. doi: 10.1016/j.jamda.2019.12.012.
18. Anker SD, Morley JE, von Haehling S. Welcome to the ICD-10 code for sarcopenia. J Cachexia
Sarcopenia Muscle 2016; 7: 512–4.
19. Cruz-Jentoft AJ, Sayer AA. Sarcopenia. Lancet 2019;393:2636-46.
20. Keller K, Engelhardt M. Strength and muscle mass loss with aging process. Age and strength loss.
Muscles Ligaments Tendons J 2014;3:346-50.
21. Martone AM, Bianchi L, Abete P, Bellelli G, Bo M, Cherubini A, et al. The incidence of sarcopenia
among hospitalized older patients: results from the Glisten study. J Cachexia Sarcopenia. Muscle
2017;8:907-14.
22. Robbins J, Gangnon RE, Theis SM, Kays SA, Hewitt AL, Hind JA. The effects of lingual exercise on
swallowing in ol-der adults. J Am Geriatr Soc 2005; 53: 1483–9.
23. Kuroda Y, Kuroda R. Relationship between thinness and swallowing function in Japanese older
adults: implications for sarcopenic dysphagia. J Am Geriatr Soc 2012; 60: 1785-6.
24. Wakabayashi H, Sakuma K. Rehabilitation nutrition for sarcopenia with disability: a combination ofboth rehabilitation and nutrition care management. J Cachexia Sarcopenia Muscle. 2014; 5(4): 269–
77.
25. Greenleaf JE. Physiological responses to prolonged bed rest and fluid immersion in humans. J Appl
Physiol 1984; 57(3): 619-33.